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Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

Menu

Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

Menu

Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

Prowers County Referral Form

VRI offers a full suite of innovative solutions and connected devices that are reliable and simple to use.

Thank you for choosing VRI

To call in a referral: 800-860-4230, Option 2

Prowers County - Referral Form

Case Manager

Name(Required)

First Last

Email(Required)

Phone(Required)

Client Information

Name(Required)

First Last

State ID(Required)

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street Address Apartment/Suite # City State / Province / Region ZIP / Postal Code

Phone 1(Required)

Phone 1 Type(Required)

Phone 2

Phone 2 Type

If client is non-english speaking, preferred language:(Required)

If client is non-english speaking, preferred language:(Required)

Type NA if not applicable

Can client be contacted directly?(Required)

Yes

No

Client's Contacts

Contact Type(Required)

This is the Preferred Contact

Contact Name(Required)

First Last

Contact Phone Type(Required)

Phone(Required)

Notes or additional contacts(Required)

Type of Equipment Needed

Personal Emergency Response Systems (PERS)(Required)

In Home Landline/Digital PERS - $40/Month

In Home Cellular PERS - $50/Month

Fall Detection Pendant - $10/Month

Extra Pendant - $5/Month

Mobile Basic - $50/Month

Mobile with fall detection + GPS - $60/Month

NA

Locked Medication Management Devices(Required)

Medication Dispenser (monitored) - $30/Month

Medication Dispenser (non-monitored) - $30/Month

NA

This field is hidden when viewing the form

Who will handle the medication for this client?(Required)

First Last

This field is hidden when viewing the form

Phone(Required)

Do you want an installer to set up the member's device(s)?(Required)

Yes ($50 one time fee)

No

Additional Notes

Is there any additional information regarding this client that would assist us with the installation?(Required)

Is there a delayed installation date?(Required)

Yes

No

Delayed installation date(Required)

Month

Day

Year

upload PAR.

Max. file size: 50 MB.

To upload a PAR, click the "Choose File" button and select the PAR to be uploaded. The file will be uploaded and saved with your referral submission.

PAR number.

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HOME

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ABOUT

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Med Management

RESOURCES

Contact
Library

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Careers

Facebook Linkedin Twitter

Terms & Conditions
Privacy Notice
Accessibility
Ethics
Service Animal Policy

Terms & Conditions
Privacy Notice
Accessibility
Ethics
Service Animal Policy

© ModivCare. All rights reserved.